If there has been a conversion, please indicate which Bet Din officiated:

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

Parents' Information

Parent/Guardian 1:*

PrefixFirst NameLast Name

Parent/Guardian 1 Cell:*

Area CodePhone Number

Home Phone:Enter if used as primary phone

Area CodePhone Number

Parent/Guardian 2:*

PrefixFirst NameLast Name

Parent/Guardian 2 Cell:*

Area CodePhone Number

Primary Address:*Enter primary address where child resides.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Secondary Address:Enter secondary address or address of Parent 2

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/Guardian 1 E-mail:*

Parent/Guardian 2 E-mail:*

Emergency Information

Emergency contact 1:*

First NameLast Name

Phone Number:*

Area CodePhone Number

Relationship to child:*

Emergency contact 2:*

First NameLast Name

Phone Number:*

Area CodePhone Number

Relationship to child:*

Doctor:*

First NameLast Name

Phone Number:*

Area CodePhone Number

Payment

Tuition includes complete year of weekly school, registration & book fees, supplies and snacks. Ask us about our referral reward!

Referral program

I referred families to Skokie Chabad Hebrew SchoolSkokie Chabad Hebrew School was referred to me by a friend.

I am paying for:*

Hebrew School - Full PaymentHebrew School - Half Payment (Remainder will be charged on September 1)Payment plan - please call to discuss

Total

$0.00

Payment

Credit Card

Credit Card Type

Credit Card Number

Security Code

Name on Card

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Skokie Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Skokie Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties. I allow my child to be photographed while participating in Skokie Chabad Hebrew School activities and acknowledge that these pictures may be used for marketing purposes.